Pilot Helps LVNs Improve Supervision Skills

Posted: Mar. 21, 2008
return to IFAS Age Newletter March 2008

The older man didn't want to wash. The more the certified nursing assistant (CNA) tried to coax him into the shower, the more agitated and belligerent the resident became. The CNA was becoming a bit agitated herself because she knew the gentleman's family members would be arriving soon for a visit and would be understandably upset if their relative wasn't ready.

Cajoling the resident wasn't working and skipping the shower wasn't an option. At her wit's end, the CNA found a licensed vocational nurse (LVN) and asked him for help. She wasn't disappointed. Soon after the LVN arrived on the scene, the man was showered, happy and calm. The crisis had been averted.

Not so fast, said educator Barbara Bowers at a recent LVN training session in northern California. During a lively exchange with the LVN who had saved the day, the director of the Geriatric Nurse Practitioner Program at the University of Wisconsin-Madison (UWM) School of Nursing gently suggested that an important teaching moment might have been missed in the rush to get the man ready for his family visit. To illustrate her point, Bowers encouraged the LVN to reexamine the incident so he could discover for himself exactly how he had solved the problem and how he might have taught the CNA to do the same thing.

"As an LVN, you need to be aware that you are thinking very critically about a complex issue," says Bowers. "Then you need to be aware of the components of your thinking process. Then you need to walk the CNA through each component so she understands what you're doing."

Training LVNs for Leadership

The encounter between Bowers and the LVN took place during the LVN Leadership Enrichment and Development project (LVN LEAD), a 15-month effort to develop, pilot and evaluate a training course that would help LVNs become more effective supervisors of frontline care workers. In addition to the critical thinking module described above, LNV LEAD participants also received instruction on coaching and supervision, conflict resolution, communications proficiency and cultural competency. Each of the training modules involved some lecturing, but LVNs spent the majority of their training time interacting with Bowers and one another as they discussed real-life examples and explored practical strategies for becoming better supervisors.

Three partners collaborated on the LVN LEAD project. Bowers and her UWM team developed the training modules and facilitated the program's two training sessions, which consisted of one, full-day meeting and one half-day follow-up session. Aging Services of California obtained project funding from the California HealthCare Foundation, identified the four nursing homes that would serve as pilot sites and is now working with local stakeholders to replicate the program. IFAS evaluated the training program through pre- and post-training focus groups and interviews with LVNs, CNAs and administrators. To advance replication efforts, the partners worked together to develop a manual that nursing homes, associations and educators can use to conduct their own training programs.

Learning to Supervise

Before attending the training sessions, many LVNs saw themselves only as "medicine nurses" and never realized that supervision was part of their job, says IFAS Policy Research Associate Alisha Sanders. In addition, few had the skills to be good supervisors and many resisted taking on management duties because they equated supervision with discipline rather than coaching. Administrator Dixie Reeve, whose facility was an LVN LEAD pilot site, says she welcomed the opportunity to help her LVNs improve their skills and was pleased to find that LVNs responded positively to that opportunity.

"They were most excited by the fact that we would invest in them in this way," says Reeve about LVNs at the Masonic Home of Union City. "They felt valued and that has made them even more committed to the facility. We wanted to create an awareness of what is expected of them and we accomplished that. Now they are looking for more."

In most facilities, providing "more" will mean creating an infrastructure that allows LVNs to use and continue to hone their new supervisory skills, says Sanders. This could involve incorporating supervisory duties into LVN job descriptions and evaluating LVNs based on their performance in this area; designing work flows so LVNs have time to supervise CNAs; providing ongoing training and education; and, most important, respecting the LVNs as facility leaders and giving them the freedom to manage. Reeve agrees.

"My attitude and the director of nursing's attitude need to be extremely open," she says. "We need to ask LVNs for their input and we need to be mentoring and coaching them constantly. We need to really listen, even if they are saying things we don't want to hear."